1

Contact Information

 *

Contact Information

Name:

Address:

City:

Zip Code:

Email Address:

Jury Service Dates:

2

Are you a US citizen?

Are you a US citizen?

Yes

No

3

Are you a resident of King County?

Are you a resident of King County?

Yes

No

4

Are you 18 years of age or older:?

Are you 18 years of age or older:?

Yes

No

5

Are you able to communicate in the English Language?

Are you able to communicate in the English Language?

Yes

No

If you answered No to any to the above questions, skip to Question #20.

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6

Have you ever been convicted of a Felony?

Have you ever been convicted of a Felony?

Yes

No

7

If Yes, have your rights been restored?

If Yes, have your rights been restored?

Yes

No

8

Marital Status

Marital Status

Married

Single

Divorced

Widowed

Separated

9

Family Information

Family Information

Spouse's name

Number of children

Ages of children

Number of children in home

10

Employment Status

Employment Status

Employed

Unemployed

Retired

11

Employer Information

Employer Information

Current employer and occupation

Name of former employer and occupation

12

Are you a licensed driver?

Are you a licensed driver?

Yes

No

13

Have you ever served as a juror?

Have you ever served as a juror?

Yes

No

14

If Yes,

when did you serve and in what County?

15

Do you have any physical conditions such as hearing, sight loss or chronic ailment which may affect your service as a juror?

Do you have any physical conditions such as hearing, sight loss or chronic ailment which may affect your service as a juror?

Yes (please explain) If other, type text here.

No

16

Can you serve as an impartial juror?

Can you serve as an impartial juror?

Yes

No

17

Have you or any member of your immediate family been party to any civil, traffic, or criminal litigation in court?

Have you or any member of your immediate family been party to any civil, traffic, or criminal litigation in court?

Yes (please provide the date of the incident(s) and which court the case was filed in.) If other, type text here.

No

18

Have you or any member of your family suffered serious bodily injury?

Have you or any member of your family suffered serious bodily injury?

Yes (please describe the injury.) If other, type text here.

No

19

Have you or any member of your immediate family, relative of close acquaintances ever been the victim of a crime?

Have you or any member of your immediate family, relative of close acquaintances ever been the victim of a crime?

Yes (please provide the date of the incident and the crime committed) If other, type text here.

No

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20

You must agree to the following to submit this form.

 *

You must agree to the following to submit this form.

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE.

I understand this communication is subject to public disclosure laws of the State of Washington (RCW 42.56)

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